esbl jasmin fauteux march 29 th 2012. plc intake 66 yo female with dysuria and pelvic pain just...
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PLC Intake
• 66 yo female with dysuria and pelvic pain
• Just returned from visit to Pakistan
• VS Normal
• Physical exam: Mild right CVA tenderness
• Seen 2d ago and given Cipro for UTI
E. Coli > 8 x 106
• Ampicillin R• Ceftriaxone R• Pip/tazo S• Cipro R• Nitrofurantoin S• TMP/SMX S
Disposition?
A new problem?
• 1940s: First β-lactamase in E. coli
• 1980s: Introduction of Cefotaxime in Europe
• 1984: First reported case of ESBL in France and Germany
• 1988: First case in US
Definitions
• Beta-lactams– Beta-lactam ring that inhibits cell wall synthesis– Penicillins, cephalosporins, carbapenems and
monobactams
• Beta-lactamase– Bacterial enzymes that open the beta-lactam ring,
inactivating the antibiotic– Currently over 600 β-lactamases
Extended spectrum β-lactamase
• Activity against oxyimino-cephalosporins (3rd generation) and monobactams but not the cephamycins
• Inhibition by beta-lactam inhibitors
• AmpC– Resitant to cephamycins and beta-lactam inhibitors
• Carbapenemase– Resistant to carbapenems
Extended spectrum β-lactamase
• Heterogeneous group
• Testing of various oxyimino-β-lactams required
Which bugs?
• All Gram-negative bacterias– Klebsiella species– E. coli– Pseudomonas– Acinetobacter– Burkholderia– Citrobacter– Enterobacter– Morganella– Proteus– Salmonella– Serratia– Shigella
CLSI SensitivityESBL Cefotaxime Ceftriaxone Cefpodoxime Ceftazidime Cefepime
Se 99,2% 99,2% 98,3% 65,3% 11,9%
Sp 40,7% 41,5% 44,9% 55,9% 99,2%
AmpC Cefotaxime Ceftriaxone Cefpodoxime Ceftazidime Cefepime
Se 100% 100% 100% 84,6% 7,7%
Sp 34,6% 41% 32,1% 39,7% 100%
Canada
ESBL Amp C Carbapenem R
E. Coli 4,4% *2,6%K. Pneumoniae 1,3%Pseudomonas 7,2% 5,6%
CANWARD 2008*CANWARD 2007-2009
Calgary E. coli
Molecular Epidemiology over an 11-Year Period (2000 to 2010) of Extended-Spectrum -Lactamase-Producing Escherichia coli Causing Bacteremia in a Centralized Canadian Region, Peirano et al, Journal of Clinical microbiology
Calgary E. Coli
• 2008-2010 Antibiograms– Sensitivity to Ceftriaxone
ACH PLC FMC RGH
E. Coli 93% 87% 90% 87%
Calgary K. pneumoniae
Molecular epidemiology of extended-spectrum-b-lactamase-producing Klebsiella pneumoniae over a 10 year period in Calgary, Canada, Peirano, G. Journal of Clinical Microbiology
Calgary Klebsiella
• 2008-2010 Antibiograms– Sensitivity to Ceftriaxone
ACH PLC FMC RGH
Klebsiella species 95% 94% 97% 98%
Calgary P. aeruginosa
• 2008-2010 Antibiograms
ACH PLC FMC RGH
Ceftazidime 93% 94% 87% 96%
Meropenem - 94% 91% 90%
• All antibiotics
• 3rd generation cephalosporins– Restriction of use caused reduction in ESBL infection
Instrumentation
• Central or arterial line• Urinary catheter• Mechanical ventilation• G/J-tube• Hemodialysis
Everything but uncomplicated UTI
• Carbapenems–Need to speak to ID– Ertapenem 1g IV q 24hrs– In patient vs outpatient
Serious bacterial infectionsTreatment
• Even with In Vitro susceptibility, we should not use:
– 3rd generation cephalosporins– 4th generation cephalosporins*– Cephamycins– Pip/tazo– Fluoroquinolones– Aminoglycosides
* Might change with 2010 CLSI, potential future therapy
Uncomplicated UTI
• If sensitive-Nitrofurantoin - 5 days-Fosfomycin* - 3g PO once
-Fluroquinolones – May be considered
*Not available in Canada
Antibiotic stewardship
• Use of narrower spectrum antibiotics– Avoiding cephalosporins and fluroquinolones
• Minimizing days of therapy
Carbapenem resistance
• Pseudomonas: 3,3%• A. Baumannii: 2,7%• E. Coli & Klebsiella: 0,1%
• Mortality:40-60%
• Contact ID & contact isolation
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